Healthcare Provider Details

I. General information

NPI: 1942771944
Provider Name (Legal Business Name): GREGORY LEWIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 OKLAHOMA AVE
TRENTON MO
64683-2565
US

IV. Provider business mailing address

118 N 2ND ST STE 200
SAINT CHARLES MO
63301-2894
US

V. Phone/Fax

Practice location:
  • Phone: 660-359-4600
  • Fax: 660-359-4286
Mailing address:
  • Phone: 636-224-1210
  • Fax: 636-946-0991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2018036512
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: